BACKGROUND Portal hypertension(PH)is a major complication of chronic liver disease and a leading cause of mortality and morbidity in patients with cirrhosis.Transjugular intrahepatic portosystemic shunt(TIPS)is an est...BACKGROUND Portal hypertension(PH)is a major complication of chronic liver disease and a leading cause of mortality and morbidity in patients with cirrhosis.Transjugular intrahepatic portosystemic shunt(TIPS)is an established treatment for PH-related complications,including refractory ascites,variceal bleeding,hepatic hydrothorax and Budd-Chiari syndrome.However,post-TIPS cardiac decompensation has been reported in up to 25%of patients,often due to haemodynamic shifts revealing occult cardiac dysfunction.Current approaches to pre-procedural cardiac assessment and risk stratification remain inconsistent.This systematic review examines current recommendations and emerging strategies for cardiovascular evaluation in patients with cirrhosis prior to a TIPS.AIM To identify the key predictive factors for cardiac decompensation following a TIPS in patients with cirrhosis.METHODS A systematic review of available literature,using PubMed(including MEDLINE),Embase and Cochrane databases.Results were searched comprehensively,without exclusion criteria,from inception to May 2025.Given the predominance of retrospective cohort studies,risk of bias assessment was primarily performed using the ROBINS-E tool.RESULTS Thirteen studies were included(n=1674 patients),with a pulled mean decompensation rate of 8.8%.Due to the variability in TIPS timing,study quality and heterogeneity,a meta-analysis was not feasible,therefore results were synthesised narratively.Multiple diastolic dysfunction parameters independently and integrated through the American Society of Echocardiography guidelines demonstrated predictive value.Newly validated risk score,heart failure with preserved ejection fraction,and biomarkers such as N-terminal pro-B-type natriuretic peptide≥125 pg/mL consistently highlight cardiac dysfunction amongst the literature.Our review also explored left-atrial strain imaging as well as recent advances in cardiac magnetic resonance imaging and potential genetic contributors.CONCLUSION Multiple predictors of cardiac decompensation following TIPS exist,however studies are of limited quality.Implementing reliable markers may enable early risk stratification,candidate selection and guide pre-procedural optimisation.展开更多
In this article,we provide commentary on the recent article by Zhao et al.We focus on the shifts in the gut microbiota of patients with hepatitis B virus(HBV)-associated cirrhosis/portal hypertension(PH)following tran...In this article,we provide commentary on the recent article by Zhao et al.We focus on the shifts in the gut microbiota of patients with hepatitis B virus(HBV)-associated cirrhosis/portal hypertension(PH)following transjugular intrahepatic portosystemic shunt(TIPS)and the implications for understanding the mechanisms,diagnosis,and treatment.By comparing the gut microbiota composition and dynamic changes before and after TIPS in patients with and without hepatic encephalopathy,the authors found an increase in non-probiotic bacteria in those who developed hepatic encephalopathy post-TIPS,with Morganella species present only in the hepatic encephalopathy group.The gut microbiota changes post-TIPS among patients without the occurrence of hepatic encephalopathy suggest potential therapeutic benefits through prophylactic microbiome therapies.Furthermore,the specific gut microbiota alterations may hold promise to predict the risk of hepatic encephalopathy in individuals undergoing TIPS for HBVrelated PH.Despite these promising findings,future studies are needed to address limitations,including a small sample size,a relatively short evaluation period for gut microbiota alterations,the absence of data on dynamic alterations in gut microbiota post-TIPS and their correlation with blood ammonia levels,and the lack of validation in animal models.In conclusion,Zhao et al's study has shed new light on the link of gut microbiota with post-TIPS hepatic encephalopathy,potentially through the intricate gut-liver axis,and has important clinical implications for improving the management of patients with HBV-related PH.展开更多
BACKGROUND Hepatic encephalopathy(HE)affects more than 30%of patients with cirrhosis.Extrahepatic portosystemic shunt(EHPSS)has been suggested to be a contributing factor to HE recurrence and mortality.Therefore,early...BACKGROUND Hepatic encephalopathy(HE)affects more than 30%of patients with cirrhosis.Extrahepatic portosystemic shunt(EHPSS)has been suggested to be a contributing factor to HE recurrence and mortality.Therefore,early detection and intervention in EHPSS may improve patient outcomes.AIM To evaluate the effects of shunt embolization on mortality and HE recurrence.METHODS In this retrospective case-control study,16 cirrhotic patients with HE treated at a tertiary care center from January 2012 to August 2022 were included.Outcomes in eight patients who underwent embolization of EHPSS were compared with those in eight patients receiving standard care without embolization.Data on baseline characteristics,HE recurrence,and overall survival were collected and analyzed using Kaplan-Meier and log-rank tests.RESULTS Baseline characteristics were comparable between the groups.The 1-year overall survival rate was significantly higher in the treatment group(0.50)than in the control group(0.33).The HE recurrence-free rate was also higher in the treatment group(1.00)than in the control group(0.17).The median survival duration was longer in the treatment group{not reached[95%confidence interval(CI):23.84 to not available(NA)]}than in the control group[15.02 months(95%CI:9.86 to NA)](P=0.006).Similarly,the recurrence-free duration was longer in the treatment group[63.09 months(95%CI:63.09 to NA)]than in the control group[9.21 months(95%CI:4.47 to NA)](P=0.006).EHPSS embolization significantly reduced 1-year HE recurrence(hazard ratio=0.09;95%CI:0.01-0.75;P=0.026).CONCLUSION EHPSS embolization significantly improves 1-year survival and prevents recurrence of HE in cirrhotic patients.Routine computed tomography and early embolization are clinically beneficial.展开更多
BACKGROUND Portal hypertension(PHT),a complication of liver cirrhosis,is sometimes managed with transjugular intrahepatic portosystemic shunt(TIPS)to reduce portal pressure.Although effective,TIPS poses risks,includin...BACKGROUND Portal hypertension(PHT),a complication of liver cirrhosis,is sometimes managed with transjugular intrahepatic portosystemic shunt(TIPS)to reduce portal pressure.Although effective,TIPS poses risks,including hepatic enceph-alopathy(HE).This study investigates whether a significant reduction in the portal pressure gradient(PPG)after TIPS improves outcomes in PHT patients.AIM To evaluate the impact of post-TIPS PPG reduction on clinical outcomes and explore the relationship between PPG reduction and portal vein diameter.METHODS This retrospective cohort study included 815 patients with PHT who underwent TIPS at two tertiary hospitals between 2014 and 2022.Patients were categorized based on whether they achieved a 50%reduction in PPG.Propensity score matching was applied to balance baseline characteristics.Kaplan-Meier analysis assessed clinical outcomes,including rebleeding,HE,liver failure,and hepato-cellular carcinoma.Cox regression identified risk factors,and Spearman correlation analyzed the relationship between PPG reduction and portal vein diameter.RESULTS Patients with a PPG reduction>50%had significantly lower risks of rebleeding(P=0.004),shunt dysfunction(P=0.002),and mortality(P=0.024)compared to those with a PPG reduction≤50%.However,these patients faced higher risks of HE(P<0.001)and liver failure(P=0.003).A significant negative correlation was observed between the percentage of PPG reduction and portal vein diameter(ρ=-0.632,P<0.001),suggesting that patients with smaller portal vein diameters may achieve greater PPG reductions.CONCLUSION A significant PPG reduction following TIPS is associated with improved clinical outcomes,including reduced risks of rebleeding,shunt dysfunction,hepatocellular carcinoma,and mortality,though it increases HE and liver failure risks.The observed correlation between portal vein diameter and PPG reduction highlights the potential role of portal vein anatomy in predicting TIPS efficacy,warranting further investigation.展开更多
BACKGROUND Hepatic encephalopathy(HE)is a poorly understood complication in hepatosplenic schistosomiasis(HSS),a neglected cause of non-cirrhotic portal hypertension.Although portosystemic shunts(PSS)are commonly obse...BACKGROUND Hepatic encephalopathy(HE)is a poorly understood complication in hepatosplenic schistosomiasis(HSS),a neglected cause of non-cirrhotic portal hypertension.Although portosystemic shunts(PSS)are commonly observed in HSS patients,the prevalence and clinical impact of overt HE(OHE)and minimal HE(MHE)remain understudied,particularly in resource-limited settings.AIM To determine OHE/MHE prevalence in HSS and its associations with PSS,clinical,and laboratory characteristics.METHODS This cross-sectional study included 200 HSS patients undergoing treatment at the Hospital of Universidade Federal de Pernambuco in Brazil between 2021 and 2023.Cognitive function was assessed using the animal naming test(ANT)and Mini-Mental State Examination(MMSE),while psychological status was evaluated with the Hospital Anxiety and Depression Scale.PSS was identified via ultrasound,and fibrosis severity was quantified using the Coutinho index(CI).Analyses were adjusted for education level and the presence of comorbidities.Statistical analyses were performed using R software.RESULTS The prevalence of OHE was 0.5%,while MHE,diagnosed via ANT,affected 24%of patients.ANT positivity was significantly associated with the presence of PSS(35.1%vs 15.1%;P=0.0018)and higher CI scores(1.79±0.26 vs 1.30±0.84;P=0.045).Patients with MHE demonstrated notably lower MMSE scores(24.06±1.17 vs 26.04±0.63;P=0.0003),independent of education level.The ANT showed high diagnostic robustness,even among patients with limited formal education.CONCLUSION MHE is prevalent in HSS,especially with PSS,and is associated with portal hypertension severity.The ANT enables practical screening,underscoring the need for routine assessment to improve outcomes.展开更多
BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is a highly effective treat-ment for complications associated with portal hypertension.However,stent fracture,although extremely rare,represents a potentia...BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is a highly effective treat-ment for complications associated with portal hypertension.However,stent fracture,although extremely rare,represents a potentially serious complication following TIPS creation.Timely identification and management are crucial for preventing further adverse events.CASE SUMMARY We report a 56-year-old male patient who underwent a TIPS procedure for re-current melena caused by portal hypertension secondary to hepatitis B and experienced a stent fracture 15 months post-procedure.He was readmitted 30 months after the initial TIPS due to recurrent esophagogastric variceal bleeding and ascites.An attempt to revise the dysfunctional shunt via a stent-in-stent approach was unsuccessful.Consequently,a parallel TIPS procedure was success-fully performed via the proximal end of the fractured stent to decompress the portal venous system.At the 1-month follow-up,the patient exhibited no recur-rent variceal bleeding,and his ascites had significantly decreased.Twelve-month postoperative monitoring revealed no hepatic encephalopathy and no recurrence of bleeding or ascites.Additionally,we review the existing literature on post-TIPS stent fractures to explore the underlying mechanisms contributing to this com-plication.CONCLUSION Early recognition and prompt intervention are essential in managing stent fractures after TIPS creation to mitigate potential risks and ensure optimal patient outcomes.展开更多
Trans-jugular intrahepatic portosystemic stent shunting(TIPSS)has been in use for many years with great results and many evolutions.The procedure essentially involves the insertion of a metal covert stent to create an...Trans-jugular intrahepatic portosystemic stent shunting(TIPSS)has been in use for many years with great results and many evolutions.The procedure essentially involves the insertion of a metal covert stent to create an Hepato-Hepatic portosystemic shunt.Over time,TIPSS has become the subject of many studies aimed at examining its clinical utility and evaluating the results of using TIPSS to manage complications related to portal hypertension.From the outset,this procedure has been met with hope and enthusiasm and give the chance to consider another possibility to treat the complications of portal hypertension without the use of surgery.Considering that TIPSS is an attractive alternative to shunt surgery because it does not require the use of general anesthesia or laparotomy,in fact this method is applicable to many patients with severe liver disease not suitable for it.TIPSS has been studied for the management of variceal bleeding,ascites,hepatic hydrothorax,hepatorenal syndrome,and other types of cirrhosis.However,some drawbacks of the TIPSS,such as shunt stenosis and hepatic encephalopathy,have also been reported in the literature.On the basis of the available evidence and the new epidemiological findings regarding liver disease,the following question may be posed:What is the place of TIPSS in current clinical practice?展开更多
BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)has an important role in the therapy of complications of portal-hypertension-related ascites.Various guidelines now indicate that TIPS is indicated for ref...BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)has an important role in the therapy of complications of portal-hypertension-related ascites.Various guidelines now indicate that TIPS is indicated for refractory ascites(RA),but TIPS for recurrent nonrefractory ascites(RNRA)achieved better clinical results.AIM To compare the clinical outcomes of TIPS for RA and RNRA in patients with complications related to portal hypertension.METHODS There were 863 patients divided into two main categories who underwent TIPS between September 2016 and September 2021.In category 1,patients had ascites without cirrhotic gastrointestinal bleeding.The patients were divided into group A(RNRA,n=183)and group B(RA,n=217).In category 2,patients had ascites and cirrhotic gastrointestinal bleeding.The patients were divided into group C(RNRA,n=328)and group D(RA,n=135).The clinical outcomes were probability of total hepatic impairment,incidence of hepatic encephalopathy(HE)and mortality.RESULTS The symptoms of ascites disappeared or were relieved within 1 week in group A compared with group B(P=0.032),and in group C compared with group D(P=0.027).By the end of follow-up,there were significant differences in the rate of RA in group A compared with group B(P=0.016),and in group C compared with group D(P=0.012).The probability of total hepatic impairment was significantly different in group A compared with group B(P=0.024),and in group C compared with group D(P=0.019).The total incidence of HE was significantly different in group A compared with group B(P=0.008),and in group C compared with group D(P=0.004).The 6-month,and 1-,2-and 3-year survival rates were significantly different between groups A and B(all P<0.05),and between groups C and D(all P<0.05).CONCLUSION TIPS has a good therapeutic effect on ascites related to cirrhotic portal hypertension,and early TIPS for RNRA can prolong survival,and prevent progression to RA.展开更多
Transjugular intrahepatic portosystemic shunt(TIPS)is widely used to treat portal hypertension and its complications patients with cirrhosis.However,managing post-TIPS hepatic encephalopathy(HE)remains a major clinica...Transjugular intrahepatic portosystemic shunt(TIPS)is widely used to treat portal hypertension and its complications patients with cirrhosis.However,managing post-TIPS hepatic encephalopathy(HE)remains a major clinical challenge.HE is characterized by a high incidence and a complex pathogenesis,influenced by various factors.Therefore,careful patient assessment and selection for TIPS is essential.While previous studies have identified several factors contributing to the occurrence of post-TIPS HE,there is a gap in the comprehen-sive integration of surgical procedural parameters and metabolic mechanisms within a multidimensional analysis.This minireview aims to optimize treatment protocols and refine management strategies by conducting a comprehensive analysis of risk factors,ultimately aiming to reduce the incidence of post-TIPS HE.展开更多
Transjugular intrahepatic portosystemic shunts(TIPSs)are generally used for the management of complications of portal hypertension in patients with decompensated cirrhosis.However,hepatic encephalopathy(HE),which impa...Transjugular intrahepatic portosystemic shunts(TIPSs)are generally used for the management of complications of portal hypertension in patients with decompensated cirrhosis.However,hepatic encephalopathy(HE),which impairs neuropsychiatric function and motor control,remains the primary adverse effect of TIPS,limiting its utility.Prompt prevention and treatment of post-TIPS HE are critical,as they are strongly associated with readmission rates and poor quality of life.This review focuses on the main pathophysiological mechanisms underlying post-TIPS HE,explores advanced biomarkers and predictive tools,and discusses current management strategies and future directions to prevent or reverse HE following TIPS.These strategies include preoperative patient assessment,individualized shunt diameter optimization,spontaneous portosystemic shunt embolization during the TIPS procedure,postoperative preventive and therapeutic measures such as nutrition management,medical therapy,fecal microbiota transplantation,and stent reduction.展开更多
The management of portal hypertension and its complications,such as variceal bleeding,in patients with cirrhosis often involves the use of nonselective betablockers(NSBBs)and a transjugular intrahepatic portosystemic ...The management of portal hypertension and its complications,such as variceal bleeding,in patients with cirrhosis often involves the use of nonselective betablockers(NSBBs)and a transjugular intrahepatic portosystemic shunt(TIPS).Both treatment modalities have demonstrated efficacy;however,each presents distinct challenges and benefits.NSBBs,including propranolol,nadolol,and carvedilol,effectively reduce portal pressure,but are associated with side effects such as bradycardia,hypotension,fatigue,and respiratory issues.Additionally,NSBBs can exacerbate conditions such as refractory ascites,hepatorenal syndrome,and hepatic encephalopathy.In contrast,TIPS effectively reduces the incidence of variceal rebleeding,controlling refractory ascites.However,it is associated with a significant risk of hepatic encephalopathy,shunt dysfunction,and procedurerelated complications including bleeding and infection.The high cost of TIPS,along with the need for regular follow-up and potential re-intervention,poses additional challenges.Furthermore,patient selection for TIPS is critical,as inappropriate candidates may experience suboptimal outcomes.Future studies comparing NSBBs and TIPS should focus on refining the patient selection criteria,enhancing procedural techniques,optimising combination therapies,and conducting long-term outcome studies.Personalised treatment approaches,costeffectiveness analyses,and improved patient education and support are essential for maximising the use of these therapies.展开更多
A recent study in World Journal of Hepatology examined the use of intravascular ultrasound(IVUS)for transjugular intrahepatic portosystemic shunt(TIPS)creation.The study concluded that IVUS significantly reduces proce...A recent study in World Journal of Hepatology examined the use of intravascular ultrasound(IVUS)for transjugular intrahepatic portosystemic shunt(TIPS)creation.The study concluded that IVUS significantly reduces procedure time,radiation exposure,and the number of needle passes compared to conventional fluoroscopic guidance.IVUS offers real-time visualization of the portal vein,but challenges remain in terms of equipment costs and the operator learning curve.TIPS creation techniques vary widely in clinical practice,where methods,such as conventional fluoroscopy,three-dimensional image fusion,electromagnetic navigation,and IVUS,are commonly employed.In this editorial,we provide a comparative analysis of these methods based on clinical experience and the literature.By evaluating the strengths and limitations of each technique,we aim to inform clinical decision-making and enhance procedural outcomes.Future developments in TIPS creation are likely to focus on hybrid techniques that combine the strengths of IVUS,electromagnetic navigation,and real-time image fusion,potentially leading to more precise,cost-effective,and accessible methods.展开更多
BACKGROUND The use of intravascular ultrasound(iUS)has been shown in multiple singlecenter retrospective studies to decrease procedure time,radiation exposure,and needle passes compared to conventional fluoroscopic gu...BACKGROUND The use of intravascular ultrasound(iUS)has been shown in multiple singlecenter retrospective studies to decrease procedure time,radiation exposure,and needle passes compared to conventional fluoroscopic guidance in the creation of a transjugular intrahepatic portosystemic shunt(TIPS).However,there are few data regarding the impact of imaging guidance modality choice on clinical outcomes.AIM To determine the impact of iUS vs fluoroscopic guidance during creation of a TIPS on procedural metrics,liver injury,shunt patency and mortality.METHODS The retrospective study cohort consisted of 66 patients who underwent TIPS creation using iUS[“iUS-guided TIPS(iTIPS)group”]and 135 patients who underwent TIPS creation using fluoroscopic guidance[“conventional fluoroscopic-guided TIPS(cTIPS)group”]at 2 tertiary academic medical centers from 2015-2019.TIPS that required variceal embolization or portal vein recanalization were excluded.RESULTS The technical success rate was 100%in the iTIPS group and 96%in the cTIPS group(P=0.17).The iTIPS group had an air kerma(266±254 mGy vs 1235±1049 mGy,P<0.00001),dose area product(5728±6518 uGy×m^(2) vs 28969±19067 uGy×m^(2),P<0.00001),fluoroscopy time(18.7±9.6 minutes vs 32.3±19.0 minutes,P<0.00001),and total procedure time(93±40 minutes vs 110±51 minutes,P=0.01)which were significantly lower than the cTIPS group.There was no significant difference in liver function test adverse event grade at 1 month.With a median follow-up of 26 months(inter quartile range:6-61 months),there was no difference between the two groups in terms of thrombosis-free survival(P=0.23),intervention-free survival(P=0.29),or patient mortality(P=0.61).CONCLUSION The use of iUS in the creation of TIPS reduces radiation exposure and procedure time compared with fluoroscopic guidance.At midterm follow-up,the imaging guidance modality did not affect shunt patency or mortality.展开更多
This is a narrative review in which the advances in technical aspects,the main indications,limitations and clinical results of the transjugular intrahepatic portosystemic shunt(TIPS)in portal hypertension(PH)are addre...This is a narrative review in which the advances in technical aspects,the main indications,limitations and clinical results of the transjugular intrahepatic portosystemic shunt(TIPS)in portal hypertension(PH)are addressed.With the emergence of the coated prosthesis,a better shunt patency,a lower incidence of hepatic encephalopathy(HE)and better survival when compared to TIPS with the conventional prosthesis are demonstrated.The main indications for TIPS are refractory ascites,acute variceal bleeding unresponsive to pharmacological/endoscopic therapy and,lastly,patients considered at high risk for rebleeding preemptive TIPS(pTIPS).Absolute contraindications to the use of TIPS are severe uncontrolled HE,systemic infection or sepsis,congestive heart failure,severe pulmonary arterial hypertension,and biliary obstruction.The control of hemorrhage due to variceal rupture can reach up to 90%-100%of cases,and 55%in refractory ascites.Despite evidences regarding pTIPS in patients at high risk for rebleeding,less than 20%of eligible patients are treated.TIPS may also decrease the incidence of future decompensation in cirrhosis and increase survival in selected patients.In conclusion,TIPS is an essential treatment for patients with PH,but is often neglected.It is important for the hepatologist to form a multidisciplinary team,in which the role of the radiologist with experience in interventional procedures is prominent.展开更多
BACKGROUND Early transjugular intrahepatic portosystemic shunts(TIPS)is a therapeutic option for acute variceal bleeding(AVB),offering a low risk of rebleeding.However,the long-term outcomes of early TIPS remain uncle...BACKGROUND Early transjugular intrahepatic portosystemic shunts(TIPS)is a therapeutic option for acute variceal bleeding(AVB),offering a low risk of rebleeding.However,the long-term outcomes of early TIPS remain unclear.AIM To evaluate the long-term outcomes for early TIPS compared with standard treatment in patients with cirrhosis and AVB.METHODS We retrospectively analyzed the clinical data of patients with AVB who underwent early TIPS or standard treatment between January 2014 and December 2023.The primary outcome was overall survival(OS).RESULTS A total of 37 patients with AVB underwent early TIPS,while 65 patients received standard treatment.Compared with the standard treatment group,the rates of uncontrolled bleeding or rebleeding in the early TIPS group were significantly lower(10.8%vs 50.8%,P<0.001).Over a median follow-up of 46 months,no statistically significant differences were observed in terms of OS(P=0.507).The presence of comorbidities was identified as an independent predictor of OS(adjusted hazard ratio=3.81;95%confidence interval:1.16-12.46).Notably,new or worsening ascites occurred less frequently in the early TIPS group(13.5%vs 38.5%,P=0.008).There was no significant difference in the rate of overt hepatic encephalopathy between the two groups(45.9%vs 36.9%,P=0.372).CONCLUSION While early TIPS is not associated with a long-term survival benefit compared with standard treatment for AVB,it is associated with reduced risks of rebleeding and ascites.展开更多
BACKGROUND The impact of transjugular intrahepatic portosystemic shunt(TIPS)on liver and spleen stiffness remains unclear,as does the association between preoperative liver and spleen stiffness and prognosis following...BACKGROUND The impact of transjugular intrahepatic portosystemic shunt(TIPS)on liver and spleen stiffness remains unclear,as does the association between preoperative liver and spleen stiffness and prognosis following TIPS.AIM To investigate changes in liver and spleen stiffness after TIPS and examines the relationship between these parameters and the prognosis of post-TIPS patients.METHODS A total of 76 patients with liver cirrhosis and portal hypertension who underwent TIPS were included.Liver and spleen stiffness was assessed using the sound touch quantify(STQ)value,determined via point shear wave elastography in ultrasound imaging.Cox regression analysis was employed to evaluate the relationship between liver and spleen stiffness and cumulative survival in TIPS patients.RESULTS The liver STQ value demonstrated a marginally decreasing trend over time(P=0.052),while the spleen STQ value showed a significantly decreasing trend(P=0.025).Spleen STQ was positively correlated with portal pressure gradient(PPG)levels(rs=0.327,P=0.025).Cox regression analysis indicated that older age[hazard ratio(HR)=1.063,95%CI:0.997-1.133,P=0.060]and a higher liver STQ value(HR=1.051,95%CI:1.009-1.095,P=0.018)were associated with an increased mortality risk after TIPS.No significant correlation was found between liver or spleen stiffness and overt hepatic encephalopathy post-TIPS.The liver STQ value[area under the receiver operating characteristic curve(AUC)=0.724(95%CI:0.563-0.884)]showed superior predictive performance compared to the Child-Pugh score[AUC=0.699(95%CI:0.529-0.870)]and was comparable to the model for end-stage liver disease score[AUC=0.746(95%CI:0.591-0.902)].CONCLUSION Following TIPS,spleen stiffness exhibited a more pronounced change than liver stiffness and was positively associated with PPG.Preoperative liver stiffness serves as a prognostic indicator for survival in patients undergoing TIPS.展开更多
BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is an effective intervention for managing complications of portal hypertension,particularly acute variceal bleeding(AVB).While effective in reducing portal...BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is an effective intervention for managing complications of portal hypertension,particularly acute variceal bleeding(AVB).While effective in reducing portal pressure and preventing rebleeding,TIPS is associated with a considerable risk of overt hepatic encephalopathy(OHE),a complication that significantly elevates mortality rates.AIM To develop a machine learning(ML)model to predict OHE occurrence post-TIPS in patients with AVB using a 5-year dataset.METHODS This retrospective single-center study included 218 patients with AVB who underwent TIPS.The dataset was divided into training(70%)and testing(30%)sets.Critical features were identified using embedded methods and recursive feature elimination.Three ML algorithms-random forest,extreme gradient boosting,and logistic regression-were validated via 10-fold cross-validation.SHapley Additive exPlanations analysis was employed to interpret the model’s predictions.Survival analysis was conducted using Kaplan-Meier curves and stepwise Cox regression analysis to compare overall survival(OS)between patients with and without OHE.RESULTS The median OS of the study cohort was 47.83±22.95 months.Among the models evaluated,logistic regression demonstrated the highest performance with an area under the curve(AUC)of 0.825.Key predictors identified were Child-Pugh score,age,and portal vein thrombosis.Kaplan-Meier analysis revealed that patients without OHE had a significantly longer OS(P=0.005).The 5-year survival rate was 78.4%,with an OHE incidence of 15.1%.Both actual OHE status and predicted OHE value were significant predictors in each Cox model,with model-predicted OHE achieving an AUC of 88.1 in survival prediction.CONCLUSION The ML model accurately predicts post-TIPS OHE and outperforms traditional models,supporting its use in improving outcomes in patients with AVB.展开更多
BACKGROUND Liver cirrhosis patients can develop various complications including bacteremia as the intestinal flora is heterologous.In those with low immunity,trauma,or following surgery,etc.,the body is susceptible to...BACKGROUND Liver cirrhosis patients can develop various complications including bacteremia as the intestinal flora is heterologous.In those with low immunity,trauma,or following surgery,etc.,the body is susceptible to concurrent systemic or local infections.Under these circumstances,even minimally invasive treatment methods such as interventional therapy like transjugular intrahepatic portosystemic shunt(TIPS)for liver cirrhosis patients can also result in complications such as infections.CASE SUMMARY A male patient with decompensated cirrhosis experienced multiple episodes of gastrointestinal bleeding and hypersplenism.He was admitted to hospital due to voluntary remedial TIPS.The patient developed a numerous intrahepatic liver abscess postoperatively.Following initial conservative treatment with intravenous antibiotics and parenteral nutrition,three months after TIPS,the liver abscess had disappeared on imaging examination.At the 6-month postoperative follow-up,outpatient re-examination showed that the patient had recovered and the liver abscess had resolved.CONCLUSION Attention should be paid to decreased blood cell counts,especially low leukocyte levels in patients with liver cirrhosis as the presence of intestinal microbiota dysregulation and portal pyemia can result in liver abscess and sepsis during invasive diagnostic and therapeutic procedures like TIPS.The addition of probiotics might reduce the risk in such patients.展开更多
BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is contraindicated for patients with cavernous transformation of the portal vein(CTPV)due to high surgery-related mortality risk.However,surgically assiste...BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is contraindicated for patients with cavernous transformation of the portal vein(CTPV)due to high surgery-related mortality risk.However,surgically assisted TIPS(SATIPS)can significantly reduce the risk.AIM To evaluate the clinical efficacy of SATIPS,this study was conducted.METHODS One hundred and seven patients with CTPV and esophagogastric variceal bleeding were recruited from January 2023 to December 2024.The patients were recruited from three different hospitals.Overall,54 patients received SATIPS treatment(SATIPS group),while 53 patients did not receive SATIPS and underwent prophylactic endoscopic sclerosing ligation(control group).Subsequently,survival rates,incidence rates of gastrointestinal bleeding,incidence of hepatic encephalopathy rate,and the incidence of liver failure after treatment in both groups at 3 and 6 months were observed.RESULTS The survival rates for the SATIPS and control groups were 94.4%and 92.5%at 3 months(P value=0.72)and 94.4%and 73.6%at 6 months(P value=0.0051)respectively.The incidence of liver failure was 3.7%and 9.4%at 3 months(P value=0.26)and 3.7%and18.9%at 6 months(P value=0.016);the incidence of gastrointestinal bleeding was 5.6%and 37.7%at 3 months(P value<0.001)and 9.3%and 47.2%(P value<0.001)at 6 months;and the incidence of hepatic encephalopathy was 3.7%and 17.0%at 3 months(P value=0.026)and 7.4%and 26.4%at 6 months(P value=0.026)respectively.CONCLUSION For patients with CTPV,there were no optimal treatment.Regarding long-term efficacy,SATIPS can significantly reduce the rate of rebleeding,hepatic encephalopathy and liver failure,and is associated with better survival.展开更多
Variceal bleeding is a serious complication of cirrhosis and portal hypertension.Despite the improvement in management of acute variceal bleed(AVB),it still carries significant mortality.Portal pressure is the main dr...Variceal bleeding is a serious complication of cirrhosis and portal hypertension.Despite the improvement in management of acute variceal bleed(AVB),it still carries significant mortality.Portal pressure is the main driver of variceal bleeding and also a main predictor of decompensation.Reduction in portal pressure has been the mainstay of management of variceal bleeding.Transjugular intrahepatic porto-systemic stent shunt(TIPSS)is a very effective modality in reducing the portal hypertension and thereby,controlling portal hypertensive bleeding.However,its use in refractory bleeding(rescue/salvage TIPSS)is still associated with high mortality.“Early”use of TIPSS as a“pre-emptive strategy”in patients with AVB at high risk of failure of treatment has shown to be superior to standard treatment in several studies.While patients with Child C cirrhosis(up to 13 points)clearly benefit from early-TIPSS strategy,it’s role in less severe liver disease(Child B)and more severe disease(Child C>13 points)remains less clear.Moreover,standard of care has improved in the last decade leading to improved 1-year survival in high-risk patients with AVB as compared to earlier“early”TIPSS studies.Lastly in the real world,only a minority of patients with AVB fulfil the stringent criteria for early TIPSS.Therefore,there is unmet need to explore role of early TIPSS in management of AVB in well-designed prospective studies. In this review, we have appraised the role of early TIPSS, patient selection anddiscussed future directions in the management of patients with AVB.展开更多
文摘BACKGROUND Portal hypertension(PH)is a major complication of chronic liver disease and a leading cause of mortality and morbidity in patients with cirrhosis.Transjugular intrahepatic portosystemic shunt(TIPS)is an established treatment for PH-related complications,including refractory ascites,variceal bleeding,hepatic hydrothorax and Budd-Chiari syndrome.However,post-TIPS cardiac decompensation has been reported in up to 25%of patients,often due to haemodynamic shifts revealing occult cardiac dysfunction.Current approaches to pre-procedural cardiac assessment and risk stratification remain inconsistent.This systematic review examines current recommendations and emerging strategies for cardiovascular evaluation in patients with cirrhosis prior to a TIPS.AIM To identify the key predictive factors for cardiac decompensation following a TIPS in patients with cirrhosis.METHODS A systematic review of available literature,using PubMed(including MEDLINE),Embase and Cochrane databases.Results were searched comprehensively,without exclusion criteria,from inception to May 2025.Given the predominance of retrospective cohort studies,risk of bias assessment was primarily performed using the ROBINS-E tool.RESULTS Thirteen studies were included(n=1674 patients),with a pulled mean decompensation rate of 8.8%.Due to the variability in TIPS timing,study quality and heterogeneity,a meta-analysis was not feasible,therefore results were synthesised narratively.Multiple diastolic dysfunction parameters independently and integrated through the American Society of Echocardiography guidelines demonstrated predictive value.Newly validated risk score,heart failure with preserved ejection fraction,and biomarkers such as N-terminal pro-B-type natriuretic peptide≥125 pg/mL consistently highlight cardiac dysfunction amongst the literature.Our review also explored left-atrial strain imaging as well as recent advances in cardiac magnetic resonance imaging and potential genetic contributors.CONCLUSION Multiple predictors of cardiac decompensation following TIPS exist,however studies are of limited quality.Implementing reliable markers may enable early risk stratification,candidate selection and guide pre-procedural optimisation.
基金Supported by Clinical Research Center for Hepatopathy and Intestinal Diseases of Fujian Province,No.2023GBYJ-YL-1.
文摘In this article,we provide commentary on the recent article by Zhao et al.We focus on the shifts in the gut microbiota of patients with hepatitis B virus(HBV)-associated cirrhosis/portal hypertension(PH)following transjugular intrahepatic portosystemic shunt(TIPS)and the implications for understanding the mechanisms,diagnosis,and treatment.By comparing the gut microbiota composition and dynamic changes before and after TIPS in patients with and without hepatic encephalopathy,the authors found an increase in non-probiotic bacteria in those who developed hepatic encephalopathy post-TIPS,with Morganella species present only in the hepatic encephalopathy group.The gut microbiota changes post-TIPS among patients without the occurrence of hepatic encephalopathy suggest potential therapeutic benefits through prophylactic microbiome therapies.Furthermore,the specific gut microbiota alterations may hold promise to predict the risk of hepatic encephalopathy in individuals undergoing TIPS for HBVrelated PH.Despite these promising findings,future studies are needed to address limitations,including a small sample size,a relatively short evaluation period for gut microbiota alterations,the absence of data on dynamic alterations in gut microbiota post-TIPS and their correlation with blood ammonia levels,and the lack of validation in animal models.In conclusion,Zhao et al's study has shed new light on the link of gut microbiota with post-TIPS hepatic encephalopathy,potentially through the intricate gut-liver axis,and has important clinical implications for improving the management of patients with HBV-related PH.
基金approved by Chungbuk National University Hospital Institutional Review Board in Cheongju,Chugbuk,South Korea(No.CBNUH2022-09-013-HE001).
文摘BACKGROUND Hepatic encephalopathy(HE)affects more than 30%of patients with cirrhosis.Extrahepatic portosystemic shunt(EHPSS)has been suggested to be a contributing factor to HE recurrence and mortality.Therefore,early detection and intervention in EHPSS may improve patient outcomes.AIM To evaluate the effects of shunt embolization on mortality and HE recurrence.METHODS In this retrospective case-control study,16 cirrhotic patients with HE treated at a tertiary care center from January 2012 to August 2022 were included.Outcomes in eight patients who underwent embolization of EHPSS were compared with those in eight patients receiving standard care without embolization.Data on baseline characteristics,HE recurrence,and overall survival were collected and analyzed using Kaplan-Meier and log-rank tests.RESULTS Baseline characteristics were comparable between the groups.The 1-year overall survival rate was significantly higher in the treatment group(0.50)than in the control group(0.33).The HE recurrence-free rate was also higher in the treatment group(1.00)than in the control group(0.17).The median survival duration was longer in the treatment group{not reached[95%confidence interval(CI):23.84 to not available(NA)]}than in the control group[15.02 months(95%CI:9.86 to NA)](P=0.006).Similarly,the recurrence-free duration was longer in the treatment group[63.09 months(95%CI:63.09 to NA)]than in the control group[9.21 months(95%CI:4.47 to NA)](P=0.006).EHPSS embolization significantly reduced 1-year HE recurrence(hazard ratio=0.09;95%CI:0.01-0.75;P=0.026).CONCLUSION EHPSS embolization significantly improves 1-year survival and prevents recurrence of HE in cirrhotic patients.Routine computed tomography and early embolization are clinically beneficial.
基金Supported by the“14th Five-Year”Talent Training Program of Beijing Shijitan Hospital,Capital Medical University,No.2023 LJRCLFQ.
文摘BACKGROUND Portal hypertension(PHT),a complication of liver cirrhosis,is sometimes managed with transjugular intrahepatic portosystemic shunt(TIPS)to reduce portal pressure.Although effective,TIPS poses risks,including hepatic enceph-alopathy(HE).This study investigates whether a significant reduction in the portal pressure gradient(PPG)after TIPS improves outcomes in PHT patients.AIM To evaluate the impact of post-TIPS PPG reduction on clinical outcomes and explore the relationship between PPG reduction and portal vein diameter.METHODS This retrospective cohort study included 815 patients with PHT who underwent TIPS at two tertiary hospitals between 2014 and 2022.Patients were categorized based on whether they achieved a 50%reduction in PPG.Propensity score matching was applied to balance baseline characteristics.Kaplan-Meier analysis assessed clinical outcomes,including rebleeding,HE,liver failure,and hepato-cellular carcinoma.Cox regression identified risk factors,and Spearman correlation analyzed the relationship between PPG reduction and portal vein diameter.RESULTS Patients with a PPG reduction>50%had significantly lower risks of rebleeding(P=0.004),shunt dysfunction(P=0.002),and mortality(P=0.024)compared to those with a PPG reduction≤50%.However,these patients faced higher risks of HE(P<0.001)and liver failure(P=0.003).A significant negative correlation was observed between the percentage of PPG reduction and portal vein diameter(ρ=-0.632,P<0.001),suggesting that patients with smaller portal vein diameters may achieve greater PPG reductions.CONCLUSION A significant PPG reduction following TIPS is associated with improved clinical outcomes,including reduced risks of rebleeding,shunt dysfunction,hepatocellular carcinoma,and mortality,though it increases HE and liver failure risks.The observed correlation between portal vein diameter and PPG reduction highlights the potential role of portal vein anatomy in predicting TIPS efficacy,warranting further investigation.
文摘BACKGROUND Hepatic encephalopathy(HE)is a poorly understood complication in hepatosplenic schistosomiasis(HSS),a neglected cause of non-cirrhotic portal hypertension.Although portosystemic shunts(PSS)are commonly observed in HSS patients,the prevalence and clinical impact of overt HE(OHE)and minimal HE(MHE)remain understudied,particularly in resource-limited settings.AIM To determine OHE/MHE prevalence in HSS and its associations with PSS,clinical,and laboratory characteristics.METHODS This cross-sectional study included 200 HSS patients undergoing treatment at the Hospital of Universidade Federal de Pernambuco in Brazil between 2021 and 2023.Cognitive function was assessed using the animal naming test(ANT)and Mini-Mental State Examination(MMSE),while psychological status was evaluated with the Hospital Anxiety and Depression Scale.PSS was identified via ultrasound,and fibrosis severity was quantified using the Coutinho index(CI).Analyses were adjusted for education level and the presence of comorbidities.Statistical analyses were performed using R software.RESULTS The prevalence of OHE was 0.5%,while MHE,diagnosed via ANT,affected 24%of patients.ANT positivity was significantly associated with the presence of PSS(35.1%vs 15.1%;P=0.0018)and higher CI scores(1.79±0.26 vs 1.30±0.84;P=0.045).Patients with MHE demonstrated notably lower MMSE scores(24.06±1.17 vs 26.04±0.63;P=0.0003),independent of education level.The ANT showed high diagnostic robustness,even among patients with limited formal education.CONCLUSION MHE is prevalent in HSS,especially with PSS,and is associated with portal hypertension severity.The ANT enables practical screening,underscoring the need for routine assessment to improve outcomes.
文摘BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is a highly effective treat-ment for complications associated with portal hypertension.However,stent fracture,although extremely rare,represents a potentially serious complication following TIPS creation.Timely identification and management are crucial for preventing further adverse events.CASE SUMMARY We report a 56-year-old male patient who underwent a TIPS procedure for re-current melena caused by portal hypertension secondary to hepatitis B and experienced a stent fracture 15 months post-procedure.He was readmitted 30 months after the initial TIPS due to recurrent esophagogastric variceal bleeding and ascites.An attempt to revise the dysfunctional shunt via a stent-in-stent approach was unsuccessful.Consequently,a parallel TIPS procedure was success-fully performed via the proximal end of the fractured stent to decompress the portal venous system.At the 1-month follow-up,the patient exhibited no recur-rent variceal bleeding,and his ascites had significantly decreased.Twelve-month postoperative monitoring revealed no hepatic encephalopathy and no recurrence of bleeding or ascites.Additionally,we review the existing literature on post-TIPS stent fractures to explore the underlying mechanisms contributing to this com-plication.CONCLUSION Early recognition and prompt intervention are essential in managing stent fractures after TIPS creation to mitigate potential risks and ensure optimal patient outcomes.
文摘Trans-jugular intrahepatic portosystemic stent shunting(TIPSS)has been in use for many years with great results and many evolutions.The procedure essentially involves the insertion of a metal covert stent to create an Hepato-Hepatic portosystemic shunt.Over time,TIPSS has become the subject of many studies aimed at examining its clinical utility and evaluating the results of using TIPSS to manage complications related to portal hypertension.From the outset,this procedure has been met with hope and enthusiasm and give the chance to consider another possibility to treat the complications of portal hypertension without the use of surgery.Considering that TIPSS is an attractive alternative to shunt surgery because it does not require the use of general anesthesia or laparotomy,in fact this method is applicable to many patients with severe liver disease not suitable for it.TIPSS has been studied for the management of variceal bleeding,ascites,hepatic hydrothorax,hepatorenal syndrome,and other types of cirrhosis.However,some drawbacks of the TIPSS,such as shunt stenosis and hepatic encephalopathy,have also been reported in the literature.On the basis of the available evidence and the new epidemiological findings regarding liver disease,the following question may be posed:What is the place of TIPSS in current clinical practice?
文摘BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)has an important role in the therapy of complications of portal-hypertension-related ascites.Various guidelines now indicate that TIPS is indicated for refractory ascites(RA),but TIPS for recurrent nonrefractory ascites(RNRA)achieved better clinical results.AIM To compare the clinical outcomes of TIPS for RA and RNRA in patients with complications related to portal hypertension.METHODS There were 863 patients divided into two main categories who underwent TIPS between September 2016 and September 2021.In category 1,patients had ascites without cirrhotic gastrointestinal bleeding.The patients were divided into group A(RNRA,n=183)and group B(RA,n=217).In category 2,patients had ascites and cirrhotic gastrointestinal bleeding.The patients were divided into group C(RNRA,n=328)and group D(RA,n=135).The clinical outcomes were probability of total hepatic impairment,incidence of hepatic encephalopathy(HE)and mortality.RESULTS The symptoms of ascites disappeared or were relieved within 1 week in group A compared with group B(P=0.032),and in group C compared with group D(P=0.027).By the end of follow-up,there were significant differences in the rate of RA in group A compared with group B(P=0.016),and in group C compared with group D(P=0.012).The probability of total hepatic impairment was significantly different in group A compared with group B(P=0.024),and in group C compared with group D(P=0.019).The total incidence of HE was significantly different in group A compared with group B(P=0.008),and in group C compared with group D(P=0.004).The 6-month,and 1-,2-and 3-year survival rates were significantly different between groups A and B(all P<0.05),and between groups C and D(all P<0.05).CONCLUSION TIPS has a good therapeutic effect on ascites related to cirrhotic portal hypertension,and early TIPS for RNRA can prolong survival,and prevent progression to RA.
基金Supported by Hefei Natural Science Foundation,No.202341.
文摘Transjugular intrahepatic portosystemic shunt(TIPS)is widely used to treat portal hypertension and its complications patients with cirrhosis.However,managing post-TIPS hepatic encephalopathy(HE)remains a major clinical challenge.HE is characterized by a high incidence and a complex pathogenesis,influenced by various factors.Therefore,careful patient assessment and selection for TIPS is essential.While previous studies have identified several factors contributing to the occurrence of post-TIPS HE,there is a gap in the comprehen-sive integration of surgical procedural parameters and metabolic mechanisms within a multidimensional analysis.This minireview aims to optimize treatment protocols and refine management strategies by conducting a comprehensive analysis of risk factors,ultimately aiming to reduce the incidence of post-TIPS HE.
基金Supported by the National Natural Science Foundation of China,No.82270649.
文摘Transjugular intrahepatic portosystemic shunts(TIPSs)are generally used for the management of complications of portal hypertension in patients with decompensated cirrhosis.However,hepatic encephalopathy(HE),which impairs neuropsychiatric function and motor control,remains the primary adverse effect of TIPS,limiting its utility.Prompt prevention and treatment of post-TIPS HE are critical,as they are strongly associated with readmission rates and poor quality of life.This review focuses on the main pathophysiological mechanisms underlying post-TIPS HE,explores advanced biomarkers and predictive tools,and discusses current management strategies and future directions to prevent or reverse HE following TIPS.These strategies include preoperative patient assessment,individualized shunt diameter optimization,spontaneous portosystemic shunt embolization during the TIPS procedure,postoperative preventive and therapeutic measures such as nutrition management,medical therapy,fecal microbiota transplantation,and stent reduction.
文摘The management of portal hypertension and its complications,such as variceal bleeding,in patients with cirrhosis often involves the use of nonselective betablockers(NSBBs)and a transjugular intrahepatic portosystemic shunt(TIPS).Both treatment modalities have demonstrated efficacy;however,each presents distinct challenges and benefits.NSBBs,including propranolol,nadolol,and carvedilol,effectively reduce portal pressure,but are associated with side effects such as bradycardia,hypotension,fatigue,and respiratory issues.Additionally,NSBBs can exacerbate conditions such as refractory ascites,hepatorenal syndrome,and hepatic encephalopathy.In contrast,TIPS effectively reduces the incidence of variceal rebleeding,controlling refractory ascites.However,it is associated with a significant risk of hepatic encephalopathy,shunt dysfunction,and procedurerelated complications including bleeding and infection.The high cost of TIPS,along with the need for regular follow-up and potential re-intervention,poses additional challenges.Furthermore,patient selection for TIPS is critical,as inappropriate candidates may experience suboptimal outcomes.Future studies comparing NSBBs and TIPS should focus on refining the patient selection criteria,enhancing procedural techniques,optimising combination therapies,and conducting long-term outcome studies.Personalised treatment approaches,costeffectiveness analyses,and improved patient education and support are essential for maximising the use of these therapies.
基金Supported by National Natural Science Foundation of China,No.82330061The PUMC Graduate Curriculum Informatization Development Special Fund Project,No.2024YXX004The CAMS Initiative for Innovative Medicine,No.2021-I2M-1-015.
文摘A recent study in World Journal of Hepatology examined the use of intravascular ultrasound(IVUS)for transjugular intrahepatic portosystemic shunt(TIPS)creation.The study concluded that IVUS significantly reduces procedure time,radiation exposure,and the number of needle passes compared to conventional fluoroscopic guidance.IVUS offers real-time visualization of the portal vein,but challenges remain in terms of equipment costs and the operator learning curve.TIPS creation techniques vary widely in clinical practice,where methods,such as conventional fluoroscopy,three-dimensional image fusion,electromagnetic navigation,and IVUS,are commonly employed.In this editorial,we provide a comparative analysis of these methods based on clinical experience and the literature.By evaluating the strengths and limitations of each technique,we aim to inform clinical decision-making and enhance procedural outcomes.Future developments in TIPS creation are likely to focus on hybrid techniques that combine the strengths of IVUS,electromagnetic navigation,and real-time image fusion,potentially leading to more precise,cost-effective,and accessible methods.
文摘BACKGROUND The use of intravascular ultrasound(iUS)has been shown in multiple singlecenter retrospective studies to decrease procedure time,radiation exposure,and needle passes compared to conventional fluoroscopic guidance in the creation of a transjugular intrahepatic portosystemic shunt(TIPS).However,there are few data regarding the impact of imaging guidance modality choice on clinical outcomes.AIM To determine the impact of iUS vs fluoroscopic guidance during creation of a TIPS on procedural metrics,liver injury,shunt patency and mortality.METHODS The retrospective study cohort consisted of 66 patients who underwent TIPS creation using iUS[“iUS-guided TIPS(iTIPS)group”]and 135 patients who underwent TIPS creation using fluoroscopic guidance[“conventional fluoroscopic-guided TIPS(cTIPS)group”]at 2 tertiary academic medical centers from 2015-2019.TIPS that required variceal embolization or portal vein recanalization were excluded.RESULTS The technical success rate was 100%in the iTIPS group and 96%in the cTIPS group(P=0.17).The iTIPS group had an air kerma(266±254 mGy vs 1235±1049 mGy,P<0.00001),dose area product(5728±6518 uGy×m^(2) vs 28969±19067 uGy×m^(2),P<0.00001),fluoroscopy time(18.7±9.6 minutes vs 32.3±19.0 minutes,P<0.00001),and total procedure time(93±40 minutes vs 110±51 minutes,P=0.01)which were significantly lower than the cTIPS group.There was no significant difference in liver function test adverse event grade at 1 month.With a median follow-up of 26 months(inter quartile range:6-61 months),there was no difference between the two groups in terms of thrombosis-free survival(P=0.23),intervention-free survival(P=0.29),or patient mortality(P=0.61).CONCLUSION The use of iUS in the creation of TIPS reduces radiation exposure and procedure time compared with fluoroscopic guidance.At midterm follow-up,the imaging guidance modality did not affect shunt patency or mortality.
文摘This is a narrative review in which the advances in technical aspects,the main indications,limitations and clinical results of the transjugular intrahepatic portosystemic shunt(TIPS)in portal hypertension(PH)are addressed.With the emergence of the coated prosthesis,a better shunt patency,a lower incidence of hepatic encephalopathy(HE)and better survival when compared to TIPS with the conventional prosthesis are demonstrated.The main indications for TIPS are refractory ascites,acute variceal bleeding unresponsive to pharmacological/endoscopic therapy and,lastly,patients considered at high risk for rebleeding preemptive TIPS(pTIPS).Absolute contraindications to the use of TIPS are severe uncontrolled HE,systemic infection or sepsis,congestive heart failure,severe pulmonary arterial hypertension,and biliary obstruction.The control of hemorrhage due to variceal rupture can reach up to 90%-100%of cases,and 55%in refractory ascites.Despite evidences regarding pTIPS in patients at high risk for rebleeding,less than 20%of eligible patients are treated.TIPS may also decrease the incidence of future decompensation in cirrhosis and increase survival in selected patients.In conclusion,TIPS is an essential treatment for patients with PH,but is often neglected.It is important for the hepatologist to form a multidisciplinary team,in which the role of the radiologist with experience in interventional procedures is prominent.
基金Supported by the Natural Science Foundation of the Science and Technology Commission of Shanghai Municipality,No.23ZR1458300the Key Discipline Project of Shanghai Municipal Health System,No.2024ZDXK0004the Doctoral Innovation Talent Base Project for Diagnosis and Treatment of Chronic Liver Diseases,No.RCJD2021B02.
文摘BACKGROUND Early transjugular intrahepatic portosystemic shunts(TIPS)is a therapeutic option for acute variceal bleeding(AVB),offering a low risk of rebleeding.However,the long-term outcomes of early TIPS remain unclear.AIM To evaluate the long-term outcomes for early TIPS compared with standard treatment in patients with cirrhosis and AVB.METHODS We retrospectively analyzed the clinical data of patients with AVB who underwent early TIPS or standard treatment between January 2014 and December 2023.The primary outcome was overall survival(OS).RESULTS A total of 37 patients with AVB underwent early TIPS,while 65 patients received standard treatment.Compared with the standard treatment group,the rates of uncontrolled bleeding or rebleeding in the early TIPS group were significantly lower(10.8%vs 50.8%,P<0.001).Over a median follow-up of 46 months,no statistically significant differences were observed in terms of OS(P=0.507).The presence of comorbidities was identified as an independent predictor of OS(adjusted hazard ratio=3.81;95%confidence interval:1.16-12.46).Notably,new or worsening ascites occurred less frequently in the early TIPS group(13.5%vs 38.5%,P=0.008).There was no significant difference in the rate of overt hepatic encephalopathy between the two groups(45.9%vs 36.9%,P=0.372).CONCLUSION While early TIPS is not associated with a long-term survival benefit compared with standard treatment for AVB,it is associated with reduced risks of rebleeding and ascites.
基金Supported by National Natural Science Foundation of China,No.82200650Shanxi Provincial Clinical Research Center for Interventional Medicine,No.202204010501004+3 种基金the Precision Interventional Diagnosis and Treatment Technology Innovation Base for Cirrhosis and Portal Hypertension,No.YDZJSX20231B010the Natural Science Foundation of Shanxi Province,No.20210302124282 and No.202203021212046the Shanxi Province Higher Education“Billion Project Science and Technology Guidance Project”,No.2C622024120the National Natural Science Foundation of China Supporting Fund,No.Y82200650.
文摘BACKGROUND The impact of transjugular intrahepatic portosystemic shunt(TIPS)on liver and spleen stiffness remains unclear,as does the association between preoperative liver and spleen stiffness and prognosis following TIPS.AIM To investigate changes in liver and spleen stiffness after TIPS and examines the relationship between these parameters and the prognosis of post-TIPS patients.METHODS A total of 76 patients with liver cirrhosis and portal hypertension who underwent TIPS were included.Liver and spleen stiffness was assessed using the sound touch quantify(STQ)value,determined via point shear wave elastography in ultrasound imaging.Cox regression analysis was employed to evaluate the relationship between liver and spleen stiffness and cumulative survival in TIPS patients.RESULTS The liver STQ value demonstrated a marginally decreasing trend over time(P=0.052),while the spleen STQ value showed a significantly decreasing trend(P=0.025).Spleen STQ was positively correlated with portal pressure gradient(PPG)levels(rs=0.327,P=0.025).Cox regression analysis indicated that older age[hazard ratio(HR)=1.063,95%CI:0.997-1.133,P=0.060]and a higher liver STQ value(HR=1.051,95%CI:1.009-1.095,P=0.018)were associated with an increased mortality risk after TIPS.No significant correlation was found between liver or spleen stiffness and overt hepatic encephalopathy post-TIPS.The liver STQ value[area under the receiver operating characteristic curve(AUC)=0.724(95%CI:0.563-0.884)]showed superior predictive performance compared to the Child-Pugh score[AUC=0.699(95%CI:0.529-0.870)]and was comparable to the model for end-stage liver disease score[AUC=0.746(95%CI:0.591-0.902)].CONCLUSION Following TIPS,spleen stiffness exhibited a more pronounced change than liver stiffness and was positively associated with PPG.Preoperative liver stiffness serves as a prognostic indicator for survival in patients undergoing TIPS.
基金Natural Science Foundation of Guangdong Province,No.2024A1515013069.
文摘BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is an effective intervention for managing complications of portal hypertension,particularly acute variceal bleeding(AVB).While effective in reducing portal pressure and preventing rebleeding,TIPS is associated with a considerable risk of overt hepatic encephalopathy(OHE),a complication that significantly elevates mortality rates.AIM To develop a machine learning(ML)model to predict OHE occurrence post-TIPS in patients with AVB using a 5-year dataset.METHODS This retrospective single-center study included 218 patients with AVB who underwent TIPS.The dataset was divided into training(70%)and testing(30%)sets.Critical features were identified using embedded methods and recursive feature elimination.Three ML algorithms-random forest,extreme gradient boosting,and logistic regression-were validated via 10-fold cross-validation.SHapley Additive exPlanations analysis was employed to interpret the model’s predictions.Survival analysis was conducted using Kaplan-Meier curves and stepwise Cox regression analysis to compare overall survival(OS)between patients with and without OHE.RESULTS The median OS of the study cohort was 47.83±22.95 months.Among the models evaluated,logistic regression demonstrated the highest performance with an area under the curve(AUC)of 0.825.Key predictors identified were Child-Pugh score,age,and portal vein thrombosis.Kaplan-Meier analysis revealed that patients without OHE had a significantly longer OS(P=0.005).The 5-year survival rate was 78.4%,with an OHE incidence of 15.1%.Both actual OHE status and predicted OHE value were significant predictors in each Cox model,with model-predicted OHE achieving an AUC of 88.1 in survival prediction.CONCLUSION The ML model accurately predicts post-TIPS OHE and outperforms traditional models,supporting its use in improving outcomes in patients with AVB.
文摘BACKGROUND Liver cirrhosis patients can develop various complications including bacteremia as the intestinal flora is heterologous.In those with low immunity,trauma,or following surgery,etc.,the body is susceptible to concurrent systemic or local infections.Under these circumstances,even minimally invasive treatment methods such as interventional therapy like transjugular intrahepatic portosystemic shunt(TIPS)for liver cirrhosis patients can also result in complications such as infections.CASE SUMMARY A male patient with decompensated cirrhosis experienced multiple episodes of gastrointestinal bleeding and hypersplenism.He was admitted to hospital due to voluntary remedial TIPS.The patient developed a numerous intrahepatic liver abscess postoperatively.Following initial conservative treatment with intravenous antibiotics and parenteral nutrition,three months after TIPS,the liver abscess had disappeared on imaging examination.At the 6-month postoperative follow-up,outpatient re-examination showed that the patient had recovered and the liver abscess had resolved.CONCLUSION Attention should be paid to decreased blood cell counts,especially low leukocyte levels in patients with liver cirrhosis as the presence of intestinal microbiota dysregulation and portal pyemia can result in liver abscess and sepsis during invasive diagnostic and therapeutic procedures like TIPS.The addition of probiotics might reduce the risk in such patients.
文摘BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is contraindicated for patients with cavernous transformation of the portal vein(CTPV)due to high surgery-related mortality risk.However,surgically assisted TIPS(SATIPS)can significantly reduce the risk.AIM To evaluate the clinical efficacy of SATIPS,this study was conducted.METHODS One hundred and seven patients with CTPV and esophagogastric variceal bleeding were recruited from January 2023 to December 2024.The patients were recruited from three different hospitals.Overall,54 patients received SATIPS treatment(SATIPS group),while 53 patients did not receive SATIPS and underwent prophylactic endoscopic sclerosing ligation(control group).Subsequently,survival rates,incidence rates of gastrointestinal bleeding,incidence of hepatic encephalopathy rate,and the incidence of liver failure after treatment in both groups at 3 and 6 months were observed.RESULTS The survival rates for the SATIPS and control groups were 94.4%and 92.5%at 3 months(P value=0.72)and 94.4%and 73.6%at 6 months(P value=0.0051)respectively.The incidence of liver failure was 3.7%and 9.4%at 3 months(P value=0.26)and 3.7%and18.9%at 6 months(P value=0.016);the incidence of gastrointestinal bleeding was 5.6%and 37.7%at 3 months(P value<0.001)and 9.3%and 47.2%(P value<0.001)at 6 months;and the incidence of hepatic encephalopathy was 3.7%and 17.0%at 3 months(P value=0.026)and 7.4%and 26.4%at 6 months(P value=0.026)respectively.CONCLUSION For patients with CTPV,there were no optimal treatment.Regarding long-term efficacy,SATIPS can significantly reduce the rate of rebleeding,hepatic encephalopathy and liver failure,and is associated with better survival.
文摘Variceal bleeding is a serious complication of cirrhosis and portal hypertension.Despite the improvement in management of acute variceal bleed(AVB),it still carries significant mortality.Portal pressure is the main driver of variceal bleeding and also a main predictor of decompensation.Reduction in portal pressure has been the mainstay of management of variceal bleeding.Transjugular intrahepatic porto-systemic stent shunt(TIPSS)is a very effective modality in reducing the portal hypertension and thereby,controlling portal hypertensive bleeding.However,its use in refractory bleeding(rescue/salvage TIPSS)is still associated with high mortality.“Early”use of TIPSS as a“pre-emptive strategy”in patients with AVB at high risk of failure of treatment has shown to be superior to standard treatment in several studies.While patients with Child C cirrhosis(up to 13 points)clearly benefit from early-TIPSS strategy,it’s role in less severe liver disease(Child B)and more severe disease(Child C>13 points)remains less clear.Moreover,standard of care has improved in the last decade leading to improved 1-year survival in high-risk patients with AVB as compared to earlier“early”TIPSS studies.Lastly in the real world,only a minority of patients with AVB fulfil the stringent criteria for early TIPSS.Therefore,there is unmet need to explore role of early TIPSS in management of AVB in well-designed prospective studies. In this review, we have appraised the role of early TIPSS, patient selection anddiscussed future directions in the management of patients with AVB.
